What is the recommended treatment for partial tears and tendonitis in the supraspinatus tendon with underlying bony irregularity, mild subacromial bursitis with impingement on abduction, and AC joint bony irregularity?

Treatment for Supraspinatus Partial Tears with Tendonitis, Bony Irregularity, Subacromial Bursitis, and AC Joint Pathology

Begin with a structured 3-6 month trial of conservative management including physical therapy with eccentric strengthening, NSAIDs for short-term pain relief, and consider corticosteroid injection for acute symptom control; reserve surgical referral for patients who fail this conservative approach. 1, 2

Initial Conservative Management (First-Line Treatment)

Physical Therapy - Primary Treatment Modality

• Eccentric strengthening exercises are the cornerstone of treatment and may reverse degenerative tendon changes 1
• Physical therapy should focus on improving strength, flexibility, and shoulder function 3, 2
• The American Academy of Orthopaedic Surgeons recommends this as first-line treatment for partial thickness tears involving less than 50% of tendon thickness 2

Relative Rest and Activity Modification

• Reduce repetitive loading activities that stress the damaged tendon to prevent further injury and promote healing 1
• Avoid overhead activities and movements that reproduce impingement symptoms 1
• This does not mean complete immobilization, but rather strategic reduction of aggravating activities 1

Pharmacologic Management

NSAIDs for Pain Control:

• Naproxen is FDA-approved specifically for tendonitis and bursitis 4
• Recommended dosing: 500 mg twice daily or 250 mg every 6-8 hours for acute symptoms 4
• Important caveat: NSAIDs provide short-term pain relief but do not alter long-term outcomes 1
• Use the lowest effective dose for the shortest duration 4

Corticosteroid Injections:

• Subacromial corticosteroid injections are more effective than oral NSAIDs for acute-phase pain relief but do not change long-term outcomes 1
• Consider injection into the subacromial bursa for symptomatic relief, particularly with documented bursitis 5
• Can be used alongside physical therapy as part of initial conservative management 3, 2

Cryotherapy

• Apply melting ice water through a wet towel for 10-minute periods repeatedly for acute pain relief 1
• This is widely accepted and provides immediate symptomatic benefit 1

Duration of Conservative Treatment

Commit to 3-6 months of well-managed conservative therapy before considering surgical referral 1, 2

Surgical Considerations (Second-Line Treatment)

Indications for Surgical Referral:

• Persistent pain despite 3-6 months of appropriate conservative treatment 1, 2
• Significant functional limitations affecting daily activities or work 2
• Progressive weakness or inability to perform overhead activities 3

Surgical Approach:

• The primary goal is achieving tendon-to-bone healing, which correlates with improved clinical outcomes 3, 2
• Surgical techniques include arthroscopic, mini-open, or open repair (no single technique has proven superiority) 2
• Acromioplasty is NOT required for normal acromial bone morphology, including type II and III acromion 3, 2
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring 1

Post-Surgical Recovery:

• Sling immobilization for 4-6 weeks 3, 2
• Rehabilitation program lasting several months is essential 2

Prognostic Factors to Consider

Factors predicting worse outcomes:

• Presence of muscle atrophy and fatty degeneration in the supraspinatus 2
• Workers' compensation status correlates with less favorable outcomes 2
• Age and baseline activity level should guide treatment intensity 2

Treatment Modalities with Limited Evidence

The following have uncertain benefit and should not be primary treatments:

• Therapeutic ultrasound has weak evidence for consistent benefit 1
• Extracorporeal shock wave therapy (ESWT) appears safe but requires further research to clarify optimal use 1
• Iontophoresis and phonophoresis lack well-designed trials to support routine use 1

Critical Clinical Pitfall

Do not rush to surgery without an adequate trial of conservative management. The American Academy of Orthopaedic Surgeons specifically recommends initial non-surgical treatment for partial thickness tears, and most patients respond well to properly executed conservative therapy 2, 5. However, do not delay surgical referral beyond 6 months if conservative treatment clearly fails, as chronic tears with muscle atrophy have worse surgical outcomes 2.